﻿<!--
  作者：344805262@qq.com
  时间：2015-11-02
  描述：商家报备
-->
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<html>

<head>
    <meta name="viewport" id="viewport"
          content="width=device-width, minimum-scale=1, maximum-scale=1, initial-scale=1.0,user-scalable=no"/>
    <meta name="apple-mobile-web-app-capable" content="yes"/>
    <meta name="apple-mobile-web-app-status-bar-style" content="black-translucent"/>
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    <title>商家报备提交申请</title>
    <link href="../../css/css.css?v=185" rel="stylesheet" type="text/css">
    <style type="text/css">
        .divRegion select {
            width: 80px;
        }
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</head>

<body>
<div class="header" style="top: 0;">
      <span id="back" class="headleft">
        <a class="back"><i class="iconfont icon-jiantou"></i></a>
    </span>
    <span class="tbbiaoti">提交申请</span>
    <span class="headright"></span>
</div>
<!----------------内容开始---------------------------->
<div class="main">
    <div class="bgbai mbtopbottom zitidx">
        <p class="tjren mbbottom">
            <a href="javascript:void(0);">
                申请人：<label id="creater"></label>
            </a>
        </p>
        <p class="gsbiaoti mbbottom"><b>公司基本信息</b></p>
        <p class="tjren mbbottom mleft10">
            <a href="javascript:void(0);">
            <span class="wenbenkw">
              <input id="name" type="text" placeholder="公司名称(必填)" maxlength="128" class="tjsqwbk">
            </span>
            </a>
        </p>
        <p class="tjren mbbottom mleft10">
            <a href="javascript:void(0);">
            <span class="wenbenkw">
                <input id="supplier_industry" type="text" placeholder="所属行业(必填)" maxlength="128" class="tjsqwbk">
              </span>
            </a>
        </p>
        <p class="tjren1 mbbottom mleft10">
          <span class="divRegion" style="color: #999999">
              所在区域<br>
              <select class="sxhyxl" id="province">
                  <option value="0" selected='selected'>选择省</option>
              </select>
              <select class="sxhyxl" id="city">
                  <option value="0" selected='selected'>选择市</option>
              </select>
              <select class="sxhyxl" id="country">
                  <option value="0" selected='selected'>选择区</option>
              </select>
            </span>
        </p>
        <p class="tjren1 mbbottom mleft10">
            <a href="javascript:void(0);">
            <span class="wenbenkw">
          <input id="address" type="text" placeholder="详细地址(必填)" maxlength="128" class="tjsqwbk">
        </span>
            </a>
        </p>
        <p class="tjren1 mbbottom">
            <a href="javascript:void(0);">
            <span class="wenbenkw">
              <input id="phone" type="tel" placeholder="公司电话(必填)" maxlength="128" class="tjsqwbk">
            </span>

            </a>
        </p>
        <p class="gsbiaoti mbbottom"><b>联系信息</b></p>
        <p class="tjren mbbottom mleft10">
            <a href="javascript:void(0);">
            <span class="wenbenkw">
              <input id="chargeman_name" type="text" placeholder="公司负责人(必填)" maxlength="128" class="tjsqwbk">
            </span>
            </a>
        </p>
        <p class="tjren mbbottom mleft10">
            <a href="javascript:void(0);">
            <span class="wenbenkw">
              <input id="linkman_name" type="text" placeholder="联系人(必填)" maxlength="128" class="tjsqwbk">
            </span>
            </a>
        </p>
        <p class="tjren mbbottom">
            <a href="javascript:void(0);">
            <span class="wenbenkw">
              <input id="linkman_phone" type="tel" placeholder="联系电话(必填)" maxlength="128" class="tjsqwbk">
            </span>
            </a>
        </p>
        <p class="gsbiaoti mbbottom"><b>补充信息</b></p>
        <p class="tjren1 mbbottom mleft10 tjren2">
            <label style="color:#999999;line-height: 100%">信息来源</label><br>
          <span class="xxlyxz" style="float: left">
        <span class="from-1">
                  <b class="checkboxFour">
                      <input type="radio" value="4" id="checkboxFourInput_4" name="supplier_from" class="checkbox-gx">
                      <label for="checkboxFourInput_4"></label>
                  </b><label for="checkboxFourInput_4">其他渠道</label>
                </span>
          <span class="from-1">
                  <b class="checkboxFour">
                      <input type="radio" value="2" id="checkboxFourInput_6" name="supplier_from" class="checkbox-gx">
                      <label for="checkboxFourInput_6"></label>
                  </b>朋友
                </span>
          <span class="from-1">
                  <b class="checkboxFour">
                      <input type="radio" value="1" id="checkboxFourInput_7" name="supplier_from" class="checkbox-gx">
                      <label for="checkboxFourInput_7"></label>
                  </b><label for="checkboxFourInput_7">亲友</label>
                </span>
              <span class="from-1">
                  <b class="checkboxFour">
                      <input type="radio" value="3" checked="checked" id="checkboxFourInput_5" name="supplier_from"
                             class="checkbox-gx">
                      <label for="checkboxFourInput_5"></label>
                  </b><label for="checkboxFourInput_5">网络</label>
                </span>
          </span>
        </p>
        <p class="tjren1 mbbottom mleft10 tjren2">
            <label style="color:#999999;line-height: 100%">联系与否</label><br>
          <span class="xxlyxz" style="float: left">
          <span class="from-1">
                  <b class="checkboxFour">
                      <input type="radio" value="3" id="checkboxFourInput_1" name="supplier_visit_type"
                             class="checkbox-gx">
                      <label for="checkboxFourInput_1"></label>
                  </b><label for="checkboxFourInput_1">没有联系</label>
                </span>
          <span class="from-1">
                  <b class="checkboxFour">
                      <input type="radio" value="2" id="checkboxFourInput_2" name="supplier_visit_type"
                             class="checkbox-gx">
                      <label for="checkboxFourInput_2"></label>
                  </b><label for="checkboxFourInput_2">已介绍</label>
                </span>
          <span class="from-1">
                  <b class="checkboxFour">
                      <input type="radio" value="1" checked="checked" id="checkboxFourInput_3"
                             name="supplier_visit_type"
                             class="checkbox-gx">
                      <label for="checkboxFourInput_3"></label>
                  </b><label for="checkboxFourInput_3">已告知</label>
                </span>
          </span>
        </p>
    </div>
    <p id="commit" class="anniu"><a href="javascript:void(0);">提交</a></p>
</div>
<!----------------底部---------------------------->
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